Postoperative monitoring of free jejunal flaps: A composite clinical scoring system based on a 40-year institutional series and systematic review.

Abstract

Free jejunal flaps represent a well-established reconstructive option for circumferential pharyngoesophageal reconstruction following total pharyngolaryngectomy. However, postoperative monitoring remains challenging owing to their buried position and unique physiology of intestinal tissue. Although several adjunctive technologies have been proposed, no standardized intestine-specific clinical scoring system with defined escalation thresholds currently exists. A systematic review of the literature was conducted in accordance with the PRISMA guidelines. In parallel, we conducted a retrospective analysis of consecutive patients undergoing pharyngoesophageal reconstruction with free jejunal flaps at a high-volume center between 1984 and 2025. All flaps were monitored using an exteriorized sentinel segment sharing the mesenteric pedicle with the reconstructive segment. Based on routinely documented clinical findings, a composite monitoring score (0-12) incorporating four intestine-specific parameters (peristalsis, luminal secretion, serosal color, and selective pin-prick bleeding assessment) was formalized and retrospectively reconstructed. Diagnostic performance was evaluated in patients in whom the protocol generated a clinical alert. A total of 351 jejunal flaps were included. Overall flap survival was 97.7%. Vascular compromise occurred in 3.4% of the cases, with a median detection time of 2.5 h (IQR 2.0-4.0 h). Among the compromised flaps, salvage was achieved in 33.3%. Diagnostic performance analysis in the alert subgroup demonstrated 100% sensitivity, 76.5% specificity, a positive predictive value of 75%, and no missed events. This study formalizes long-standing physiology-based bedside assessment of free jejunal flaps into a reproducible clinical scoring framework with predefined decision thresholds. The proposed protocol may support timely recognition of vascular compromise, structured team communication, and consistent postoperative surveillance. It is intended to complement, rather than replace, adjunctive monitoring technologies. Prospective multicenter validation is warranted.